Failure to Provide Adequate Supervision and Safe Transfer Practices
Penalty
Summary
Facility staff failed to prevent a fall with major injury by not providing adequate supervision to a resident during a shower. The resident, who had moderate cognitive impairment, lower extremity impairment, Parkinson's Disease, a history of falls, and required assistance with personal care, was allowed to shower alone despite requiring staff supervision or touching assistance for showers and ambulation. Staff left the resident unattended in the shower room, honoring the resident's preference for privacy, and only checked on the resident periodically from outside the closed door. As a result, the resident was found on the shower room floor with a fractured pelvis and shoulder. Additionally, staff failed to use a gait belt during a transfer for another resident who required assistance from two staff members for toileting. The care plan for this resident did not specify the use of a gait belt during transfers, and staff did not use one when assisting the resident to the toilet. Both the CNA and the nurse aide involved in the transfer stated that they were not required to use a gait belt, and the administrator and DON were unaware that staff were not using gait belts during transfers for this resident. These deficiencies were identified through observation, interviews, and record review, and involved a lack of protective oversight and failure to follow safe transfer practices for residents with known risks for falls and injury.